Access to Emergency Contraception for Adolescents

To the Editor: In 2009, the US Food and Drug Administration facilitated access to emergency contraception among adolescents by making it available over-the-counter to individuals aged 17 years or older. A disproportionate number of teen pregnancies occur among adolescents from disadvantaged neighborhoods.^1-3 The availability and accessibility of emergency contraception in these neighborhoods relative to more affluent ones is unknown.

One possibility is that pharmacies in low-income communities are more likely to stock emergency contraception and are more versed in regulations regarding over-the-counter dispensing. Conversely, suboptimal access to many health services has been documented for low-income populations,^4,5 and pharmacy staff could be less likely to convey accurate information. We sought to understand differences in availability of and access to emergency contraception across low- and non–low-income US neighborhoods.

From September to December 2010, female research assistants posing as adolescents who recently had unprotected intercourse were randomly assigned to call every commercial pharmacy in Nashville, Tennessee; Philadelphia, Pennsylvania; Cleveland, Ohio; Austin, Texas; and Portland, Oregon. We chose cities in geographically diverse states without pharmacy access laws that supersede uniform federal regulations. Lists of pharmacies were obtained from state boards of pharmacy. Calls were made weekdays between 9 AM and 5 PM, when pharmacies would presumably be fully staffed. Callers followed standardized scripts (Figure; details available on request) to simulate real-world calls and elicit specific information on emergency contraception availability and access. We examined same-day availability of emergency contraception, whether emergency contraception could be accessed by the caller, and whether the pharmacy communicated the correct age at which emergency contraception is accessible over-the-counter.

Census data from 2010⁶ were merged with pharmacy addresses to determine the median household income of each pharmacy's census block group; 200% of the 2010 federal poverty level was considered low-income. We compared outcome measures across low-income vs non–low-income neighborhoods using logistic regression models, clustering by city, and adjusting for whether the pharmacy was independent or a chain. To exclude the possibility of differential findings between pharmacy chains, we repeated the analyses adjusting for pharmacy chain (eg, CVS/pharmacy, Walgreens) as a fixed effect. The Boston University Medical Center institutional review board deemed this study to be non–human subjects research.

Of 943 commercial pharmacies, 687 (72.9%) were chains (≥4 locations); 432 (47%) were located in low-income neighborhoods; and 916 addresses (97%) were successfully linked with census data and included in the analysis. Missing census information was distributed evenly across cities. The average cost of emergency contraception without insurance was $45 (range, $15-$65).

The availability of emergency contraception did not differ based on neighborhood income (Table). However, in 19% (n = 138) of calls, the adolescent was told she could not obtain emergency contraception under any circumstance. This misinformation occurred more often (23.7% vs 14.6%) among pharmacies in low-income neighborhoods (adjusted odds ratio [AOR], 1.93; 95% CI, 1.53-2.43). When callers queried the age threshold for over-the-counter access, they were given the correct age less often by pharmacies in low-income neighborhoods (50.0% vs 62.8%; AOR, 0.59 [95% CI, 0.45-0.79]). In all but 11 calls, the incorrect age was stated as erroneously too high, potentially restricting access. Adjusting analyses for pharmacy chain as a fixed effect yielded virtually identical results.

Although we found approximately 80% same-day availability of emergency contraception in US metropolitan areas, misinformation regarding access was common—particularly in low-income neighborhoods. Although our design did not permit us to determine why disparities in access to emergency contraception exist, possible explanations include differences in pharmacy staffing or training, frequency of requests for information, or organizational cultures around customer service. Our study assessed only telephone calling and not in-person visits. Limitations withstanding, the finding that misinformation regarding emergency contraception access is more common in low-income neighborhoods, which have higher teen pregnancy rates, suggests that targeted education for consumers and pharmacy staff may be necessary.

Published online: December 19, 2011 (doi:10.1001/jama.2011.1949).

Author Contributions: Dr Wilkinson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Wilkinson, Silverstein.

Acquisition of data: Wilkinson, Fahey, Suther.

Analysis and interpretation of data: Wilkinson, Fahey, Cabral, Silverstein.

Drafting of the manuscript: Wilkinson, Fahey, Suther, Cabral, Silverstein.

Critical revision of the manuscript for important intellectual content: Cabral, Silverstein.

Statistical analysis: Wilkinson, Cabral, Silverstein.

Administrative, technical or material support: Wilkinson, Fahey, Suther.

Study supervision: Wilkinson, Silverstein.

Obtained funding: Wilkinson, Silverstein.

Funding/Support: The Joel and Barbara Alpert Endowment for the Children of the City and Boston University School of Medicine provided funding for the study.

Role of the Sponsors: The Joel and Barbara Alpert Endowment for the Children of the City and Boston University School of Medicine did not play any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Additional Contributions: We thank Christine Shields, RN, who contributed greatly to the data collection as a paid research assistant. (Ms Shields is now with South Shore Home and Health Resources, Braintree, Massachusetts.)